PWS ID Number / PWS Name
Contact Name / Phone Number / E-Mail
Treatment Plant Surface Water (TPSW) Number1 / TPSW Name
1. Name of Water Source(e.g., Lake Tahoe, Potomac River, XYZ Canal) / ______
2. Source Type / Flowing Stream or Canal
Lake/Reservoir
GUDI (Ground Water Under the Direct Influence of Surface Water)
3. Surface Water Source Sampling Intake Location ID2 / Use State assigned number, if applicable ______
4. Source Usage
Describe conditions, constraints and months of operation on page 2. / Year Round
Part Year
Emergency
5. Proportion of typical average daily flow. / ______(Indicate %)
6. Recycling Practices
Describe recycling practices on page 2. / Return flow location marked on schematic?
Do not recycle backwash
7. Pretreatment Practices / Pretreatment
Bank Filtration
Off-Stream Storage
No pretreatment practices prior to sampling point
None
8. Chemical Pretreatment3
Describe locations and chemical pretreatment practices on page 2. / System applies following chemicals prior to source water treatment:
Copper sulfate or other algaecide / bactericide
Chlorine or potassium permanganate
Other chemicals
No chemical addition prior to sampling point
9. Sample Compositing Procedure / Blended sample tap?
Composite sample? Which sources:______
Weighted samples value? ______
N/A
1Treatment Plant Surface Water Number: Use the State-issued Facility ID (example: TPSW001), used for reporting on page 1 of DWAR 15 A & B, or check with regulator.
2Surface Water Source Sampling Intake Location: Sample Site ID numbers. Use the state-issued sampling point ID number for this location (example: RW001,etc.), or the system may provide its own identifier.
3Chemical Pretreatment: Include all chemicals used between the water source and the treatment plant. This may include, but is not limited to, coagulants, algaecides, oxidants, disinfectants; and recycled filter backwash water.
PWS ID Number / PWS Name
TPSW Number / TPSW Name
1. Source Usage Describe conditions, constraints and months of operation:
2. Recycling Practices Describe all filter backwashing recycling practices:
3. Chemical Pretreatment3 -Indicate the location of any chemical pretreatment on plant schematic and provide a full description of chemical addition practices below, specifically:
  • Systems using copper sulfate or another algaecide or bactericide in the system’s reservoirs, specify the dates that copper sulfate has already been applied, and the dates proposed to apply copper sulfate.
  • Systems feeding chlorine or potassium permanganate at the intake, explain how this will be accomplished.
  • Systems using any other chemical(s), provide details on any other chemical(s) added to the raw water, or the source.
IMPORTANT NOTE: Do not discontinue the use of any chemical, if this could have an adverse effect or present a risk to health. If unsure, please contact ADEQ or MCESD before discontinuing any chemical usage.
4. Additional Information - Include any additional information that ADEQ or MCESD(if MCESD regulated) should consider when evaluating the monitoring location(s) here, or as an attachment.

Submit the completed form to the system’s regulatory agency:

LT2 Rule SpecialistManager

Drinking Water Monitoring and Protection UnitSafe Drinking Water Program

Arizona Department of Environmental Quality Maricopa County Environmental Services Department

1110 W. Washington St., Mail Code 5415 B-21001 N Central Avenue, Suite 250

Phoenix, AZ 85007Phoenix, AZ 85004

Fax: 602-771-4634Desk: 602.506.6935 | Fax: 602.372.0866

DWAR 20 (Worksheet)

December 2014

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